Individual at Acklington

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Acklington,
in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is a report into the death of a man at HMP Acklington in January 2009. The
man died from natural causes. He was 69 years old, but frail and appeared older
than his years. A post mortem showed that the man died from a coronary artery
atheroma.
I offer my sincere condolences to the man’s family and friends for their loss. One of
my Family Liaison Officers contacted his family at the start of the investigation.
The investigation was carried out on my behalf by my colleague. Both he and I
would like to thank the Governor and all of his staff for their full and ready co-
operation during the course of our enquiries. I also thank the local Primary Care
Trust for the appointment of a clinical reviewer.
As the man died from natural causes, the findings of the clinical review play an
essential part in my report. The review shows that he received generally good care
whilst in custody, although there were some shortcomings that should be addressed.
I make two recommendations: one about medical and risk assessments being
conducted at HMP Holme House before prisoners are transferred, the other about
obtaining medical information from the community. I also recognise the good
practice in family liaison demonstrated both by Acklington and HMYOI Lancaster
Farms.
The man died just three days after his transfer to Acklington from HMP Holme
House. It was his first time in prison and he had only been in custody for a month.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary
The Investigation Process
HMP Acklington
HMP Holme House
Key Findings
Issues
Recommendations
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SUMMARY
The man appeared at Teesside Crown Court in December 2008 and was sentenced
to six years in prison for sex offences. He was sent to HMP Holme House where an
Initial Reception Healthcare assessment was undertaken. He suffered from anxiety,
chronic obstructive pulmonary disease (COPD) (narrowing of the airways causing
shortness of breath), and gout (inflammation of joints, tendons and surrounding
tissues caused by excess uric acid in the blood), and was prescribed many
medications. During his time at Holme House, the man saw the prison doctors on
four separate occasions when his medication was reviewed and repeat prescriptions
were given
In January 2009, the man transferred to HMP Acklington. Another Initial Reception
Healthcare Assessment confirmed his medical conditions and medication. The
nurse noticed his frailty and that he was unable to negotiate stairs. The following
day, the prison doctor confirmed his medication and that he appeared much older
than his actual age.
Three days afterwards, an Officer Support Grade (OSG) conducted the early
morning roll check at 5.45am on H wing. When he came to check on the man in cell
H1-16, he looked through the observation hatch and was unable to see him on his
bed. The OSG called for assistance and an Officer responded.
At 5.52am, both members of staff went into the cell and found the man sitting on the
toilet in a slumped position. The Officer checked for vital signs in his neck and wrist
but there was no pulse, he was cold to the touch and his body was stiff and rigid. It
was the Officer’s opinion that he had been dead for some time and that commencing
resuscitation was inappropriate. The Night Orderly Officer arrived shortly afterwards
and also concluded that the man had been dead for some time.
The man’s next of kin was recorded as being his brother who lived some
considerable way away. Due to the distance involved it was decided to ask HMYOI
Lancaster Farms to tell the family of his death. The duty Governor and prison
chaplain visited his family at 10.30am that morning. The man’s family had contacted
the Prison Service when he was convicted to say that they did not want any contact
with him, and they reiterated that they did not want any contact with Acklington.
In accordance with the family’s wishes, the Governor from Acklington made the
arrangements for the man’s funeral and disposal of his property and belongings.
The Governor from Acklington maintained formal contact with the family by letter to
inform them of the actions the prison had taken. The man’s funeral took place on 23
January and was conducted by the prison chaplain.
Two principal issues arise from this investigation. I emphasise that prisoners’
medical records, where appropriate, should be obtained from community
practitioners and recommend that the processes for prisoner transfers should be
reviewed. I also commend the Governor for his work at HMP Acklington.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 10 January 2009 when my investigator issued
notices announcing the investigation to staff and prisoners. The notices included
an invitation to those who wished to submit information relating to the man’s
death to make themselves known to my investigator. No prisoners came
forward as a result.
2. The investigator visited HMP Acklington on 26 January. During his visit he was
also given copies of all documentation relating to the man. My investigator
returned on 23 February and interviewed eight members of staff. The
investigator also visited HMP Holme House on 5 March and interviewed four
members of staff.
3. The local Primary Care Trust asked a clinical reviewer to carry out a review of the
man’s clinical care. My investigator and the clinical reviewer jointly discussed
aspects of his treatment with healthcare staff at Acklington and Holme House.
4. My investigator contacted Her Majesty’s Coroner for North Northumberland to
inform him of the nature and scope of my investigation and request a copy of the
Post Mortem report. Upon completion, my report will be sent to the Coroner to
assist his enquiries into the man’s death.
5. One of my Family Liaison Officers contacted the man’s family about the
investigation but they did not wish to participate in the process.
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HMP ACKLINGTON
6. HMP Acklington opened in 1972 as a category C prison. The prison is situated
on a former RAF station near Amble in Northumberland and has the capacity to
house 946 prisoners.
7. Healthcare is provided by the local Primary Care Trust. Nurses and a prison
doctor (provided through a local practice) deliver primary healthcare during the
daytime, seven days a week. There is no out of hours medical cover at the
prison, although a doctor can be contacted by prison staff over the telephone
after 6.00pm. Prisoners who require inpatient nursing care are transferred to an
outside hospital or another prison.
8. Her Majesty’s Chief Inspector of Prisons last reported on Acklington following an
announced inspection in December 2006. The Chief Inspector was disappointed
at what she found at Acklington, and concluded that it did not provide a safe and
decent environment. However, she did consider that healthcare had improved in
recent years, although there was still room for further improvement.
9. The Independent Monitoring Board Annual Report for 2006-07 strongly criticised
the standard of accommodation on several wings at Acklington.
10. Since April 2004 when I began investigating all deaths in prison custody in
England and Wales, 17 prisoners have died in Acklington including the man. Of
the 16 previous cases that I have investigated, ten were due to natural causes.
HMP HOLME HOUSE
11. Holme House is a purpose built local Category B prison, which opened in May
1992. It primarily serves the Tees Valley, South West Durham, East Durham and
North Yorkshire. It has the capacity for 994 prisoners, who are housed in a total
of six residential units known as house blocks one to six.
12. The local Primary Care Trust is the provider of healthcare services at Holme
House. There is an inpatient unit with 28 beds and 24 hour nursing care. An out
of hours doctor’s service is covered by the prison doctor with help from an
emergency medical service.
13. HM Chief Inspector of Prisons conducted an announced inspection of Holme
House in April 2005. Following the inspection, she said of Holme House:
“There was no evidence of disrespectful treatment of prisoners, although there
were some instances of staff dealing with prisoners in a superficial manner or
without regard to their individual needs. The healthcare department provided
a good range of clinical services, although in our survey prisoner perceptions
of the quality of healthcare were below the benchmark. There had been
problems in the recruitment of GPs but this was being addressed. Inpatient
care was provided in decent, clean surroundings but there was limited
opportunity for patients to associate. The mental health in-reach service
provided a good service to prisoners in the house blocks.”
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14. The most recent report by the prison’s Independent Monitoring Board (IMB) was
issued in 2005. This presented a generally favourable view of all areas of the
prison. The following comment was made of healthcare:
“There are concerns by nursing staff due to the rapid turnover of staff. The
perception is that qualified staff appointments within the prison are merely as
a stop-gap or stepping stone jobs. The unit has benefited from inclusion in
the roster of two officers easing safety and security issues.”
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KEY FINDINGS
15. The man was born in October 1939, and lived in the Cleveland area prior to his
conviction. He had been married but divorced some 30 years previously. Due to
the nature of his conviction, members of his family decided not to maintain
contact with him after he was sentenced, and had made this known to the Prison
Service.
16. In December 2008, the man appeared at Teesside Crown Court and was
sentenced to six years in prison for sex offences. He was sent to HMP Holme
House where an Initial Reception Healthcare assessment was undertaken by the
reception nurse. This was the man’s first time in prison, and he said that he had
no thoughts of self harm but did suffer from anxiety. He told the reception nurse
that he felt quite unwell.
17. The man told the nurse that he had been treated in James Cook Hospital eight
weeks earlier, and had been diagnosed as suffering from chronic obstructive
pulmonary disease (COPD) and gout. He said he had also seen his doctor the
week before attending court as he had a chest complaint.
18. The reception nurse confirmed that the man was prescribed multiple medication
for chest and breathing problems. The medication he had been prescribed was
Phyllocontin (treatment of COPD), Ventolin inhaler (treatment of asthma),
Allopurinol (treatment of gout), Clenil Modulite inhaler (treatment for asthma),
Salmeterol xinafoate accuhaler (long acting drug for treatment of COPD and
asthma), Prednisolone (anti-inflammatory medication), Diazepam (treatment for
anxiety), Tiotropium (inhaled medication for treatment of COPD) and Co-codamol
(combination of codeine and paracetamol for moderate pain relief).
19. On 15 December, the man had a review of his medication with the duty doctor.
In addition to his existing medication the doctor prescribed cod liver oil capsules.
Four days later, the duty doctor saw him again as he was complaining of acute
swelling of his right knee. The doctor prescribed Colchicine (treatment for gout)
and gave him a Methylprednisolone acetate injection (anti-inflammatory steroid
injection).
20. A healthcare nurse saw the man on 25 December as he was experiencing pain in
his groin. The healthcare nurse gave him a urine sample bottle and said that, if
the pain continued over the next few days, he should provide a sample so that
tests could be completed.
21. The man was next seen by a second duty doctor five days later and the doctor
authorised a repeat prescription of Clenil Modulite and the Salmeterol inhaler.
On 5 January 2009, the second duty doctor saw the man again and completed a
urine sample test to check his potassium levels. The test was necessary
because of the amount of medication the man was taking, and especially the
Phyllocontin. The results were recorded as being within normal limits. The
second duty doctor authorised a repeat prescription of Allopurinol and
Phyllocontin.
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22. The next day (6 January 2009), the man was transferred to HMP Acklington as
that establishment has a vulnerable prisoners unit which runs the sex offender
treatment programme. Prisoners should be assessed as fit before they are
transferred, but there is no record to confirm that the man was fit for transfer and
no risks were identified. He arrived at the prison at 12.10pm and had another
Initial Reception Healthcare Assessment by a nurse which confirmed his
conditions and medication. The nurse recorded how frail the man was and that
he was unable to negotiate stairs. Later that day, he was seen by a second
nurse in the doctor’s surgery. The second nurse recorded that he looked very
frail, pale and was shaking. It also appeared that he suffered from dribbling
incontinence. He was referred to see the doctor the next day.
23. The following day, the prison doctor reviewed the man’s medication. The prison
doctor also recorded how frail he was, and that he appeared much older than his
actual age. The man was also seen by the second nurse who asked about any
incontinence problems. He denied that he had any bladder or bowel problems.
He told the second nurse that he could manage his own personal hygiene, but
only had a shower about twice a month. He was given advice about the
importance of personal hygiene. The second nurse also recorded that he
appeared to be feeling low, confused, and had a marked tremor.
24. Just two days afterwards, the OSG conducted the early morning roll check on H
wing at 5.15am. When he came to check on the man in cell H1-16, he looked
through the observation hatch and was unable to see him on his bed. The OSG
went to the wing office to call for assistance. An Officer responded and joined the
OSG outside the man’s cell. At 5.52am, they both entered the cell and found him
sitting on the toilet in a slumped position. The Officer checked his neck and wrist
but there was no pulse, he was cold to the touch, and his body was stiff and rigid.
It was the Officer’s opinion that he had been dead for some time and that
commencing resuscitation was inappropriate. The OSG had previously worked
for a funeral director and, based on his experience, he agreed with the Officer’s
assessment of him.
25. The Officer and the OSG locked the cell and went to the wing office to call the
Night Orderly Officer. The Officer opened a death in custody log to record
events. The Night Orderly Officer arrived on H wing shortly after 6.00am and
went with the Officer and OSG to the man’s cell. The Night Orderly Officer
concurred with the decision not to attempt resuscitation. He sealed the man’s
cell and then contacted the on call doctor the duty governor. The on call doctor
pronounced the man dead at 7.10am.
Events following the man’s death
26. The man’s next of kin was recorded as his brother who lived some considerable
distance away. Due to the distance involved, the decision was taken to contact
the nearest establishment to the family, HMYOI Lancaster Farms, to request the
assistance of the Family Liaison Officer. Lancaster Farms were happy to assist
and the Governor and prison chaplain went to visit the man’s family.
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27. The Governor and prison chaplain arrived at the man’s brother’s house at
10.30am. They spoke to his sister-in-law, and informed her of his death. She
said that she and her husband did not want anything to do with him. She said
that her husband had contacted the Prison Service when the man was convicted
to say that they did not want any contact and this remained the case. This
included any involvement with the funeral and his personal property.
28. The man’s sister-in-law became upset and the prison chaplain offered support,
and he and the Governor stayed at her request. The Governor advised the
man’s sister-in-law that the Prisons and Probation Ombudsman would be in
contact at some point in the near future.
29. As a result of the family’s wishes, another Governor acted as a liaison point at
Acklington. He made the arrangements for the man’s funeral and disposal of his
property and belongings. This included contact with all known financial
institutions and the Department for Work and Pensions to cease payments of any
state benefits. The prison’s liaison officer wrote to the family to inform them of
the actions the prison had taken. The man’s funeral took place on 23 January
and was conducted by the prison chaplain.
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ISSUES
Clinical care
30. The clinical review makes the following comments concerning the clinical care
that the man received whilst in prison:
“On his admission to prison the man presented as a chronically ill man with
severe breathing problems. There is a lack of clarity in his record from HMP
Holme House as to when he was discharged from healthcare to a normal
wing and on whose authority.
The man’s blood pressure was high on admission but this was never followed
up. It is not recorded when or if secondary screening took place. There is no
record as to whether his GP or James Cook Hospital were contacted for
further clinical information. Valuable information can be gained by obtaining a
copy of a prisoner’s GP medical records particularly in cases where there is a
large amount of prescribed medication.”
31. The clinical reviewer concludes that Holme House provided “appropriate medical
care” and that the care provided by Acklington appeared “exemplary”.
The Head of Healthcare at Holme House should review the administrative
processes to ensure that medical records are obtained for prisoners who
have known medical interventions in the community prior to coming into
prison.
Transfer from Holme House to Acklington
32. Holme House transfers many prisoners to jails within its geographical area. In
the man’s case, due to his age and offences, he was transferred to Acklington
which has a vulnerable prisoners unit. However, unlike Holme House, Acklington
does not have a 24 hour healthcare.
33. The clinical review comments that:
“It is not recorded in the medical record if healthcare advice was obtained
before the man was transferred to HMP Acklington but it is clear from the
entries in his medical record that he was in a poor physical state on his
arrival.”
34. It is clear that the man was poorly when he was transferred from Holme House.
From the evidence in the records, it is not possible to make any comment as to
whether his transfer to Acklington was appropriate or not.
The Governor and Head of Healthcare at Holme House should review the
transfer process to ensure that full medical and risk assessments are
completed prior to prisoner transfer.
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Family Liaison
35. Acklington appropriately followed the guidance given in PSO 2710, “Follow up to
death in custody”. As the man’s next of kin lived in Cumbria it was sensible to
ask Lancaster Farm to provide a prompt face to face visit to break the sad news
to his family.
36. A debrief was held for all the staff involved later on the morning of 9 January.
Each member of staff was informed that support was available both whilst at work
and when off duty. Contact numbers were given for the care team and for the
prison’s liaison officer. All the staff who spoke to my investigator said that they
had nothing but praise for the care team, specifically mentioning the prison’s
liaison officer.
37. Extra work was also done by the prison’s liaison officer in arranging the man’s
funeral and handling all external communications. This was because the man’s
next of kin did not want to have any involvement with him or the prison. The
prison’s liaison officer maintained contact with the family by letter to inform them
of the date of the funeral and to obtain permission to dispose of the man’s
property.
I commend the work carried out by the prison’s liaison officer in following
the best practice in PSO 2710 and undertaking additional work on the
man’s behalf.
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RECOMMENDATIONS
1. The Head of Healthcare at Holme House should review the administrative
processes to ensure that medical records are obtained for prisoners who have
known medical interventions in the community prior to coming into prison.
2. The Governor and Head of Healthcare at Holme House should review the
transfer process to ensure that full medical and risk assessments are completed
prior to prisoner transfer.
3. I commend the work carried out by the prison’s liaison officer in following best
practice in PSO 2710 and undertaking additional work on the man’s behalf.
At the time of issuing this report there had been no comments or agreed actions to
the recommendations.
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